Basic Information:



Age: 56 Sex: Male Ethnicity: Taiwan Occupation: bakery maker Marriage status: Married Admission Date: Sep. 11, 2010

Source and reliability of information: Patient himself, reliable

Chief Complaint: Chest pain for 5 days

Present Ilness:

This 56-y/o male, diabetic patient was admitted on Feb. 2nd due to mild left chest pain since 5 days ago. He was well before until the chest pain developed.

The chest pain was sharp in nature, located in the left lower chest area, persisted for whole day, and aggravated during deep inspiration. He cannot recall the onset of pain, as it appeared insidiously. At the same time, fever developed during the recent 2 days.

The fever is intermittent in nature and is evident at afternoon. No chillness was observed.

The pain was not radiated to jaw or left shoulder area. No diaphoresis was noted.

There was no tearing chest pain or hemoptysis. No recent chest trauma history and no purulent sputum were noted. He did not notice any skin rash over his chest.

He went to our ER this morning, and a CXR showed left pleural effusion. A thoracentesis revealed the effusion as an exudate with a pH lower than 7.2, a LDH higher than 1000. He was admitted for further management after a chest tube insertion.

Past history: Appendectomy 30 years ago

Diabetes mellitus for 15 years

Left leg cellulitis 2 years ago

Medical history: Glibenclamide 1# bid, Glucophage 1 tid for sugar control

Allergy history: NKDA

Social history: smoking (-), drinking: Beer about 2 cans a day for 20 years

Travel history: no recent travel within 6 months.

Family history:

Review of System:


□ Weight loss or gain

□ Fatigue

■ Fever or chills


□ Rashes

□ Lumps

□ Itching


□ Headache


□ Decreased hearing

□ Ringing in ears (tinnitus)


□ Vision

□ Glasses or contacts

□ Pain

□ Redness


□ Stuffiness

□ Discharge

□ Itching


□ Teeth

□ Gums

□ Bleeding

□ Weakness

□ Trouble sleeping

□ Dryness

□ Color changes

□ Hair and nail changes

□ Head injury

□ Earache

□ Drainage

□ Blurry or double vision

□ Flashing lights

□ Glaucoma

□ Cataracts

□ Hay fever

□ Nosebleeds

□ Sinus pain

□ Dentures

□ Sore tongue

□ Dry mouth

□ Sore throat

□ Hoarseness

□ Thrush


□ Lumps

□ Swollen glands


□ Lumps

□ Pain

□ Discharge


□ Cough (dry or wet, productive)

□ Sputum (color and amount)

□ Coughing up blood (hemoptysis)


□ Chest pain or discomfort

□ Tightness

□ Palpitations


□ Swallowing difficulties

□ Heartburn

■ Change in appetite

□ Nausea

□ Change in bowel habits


□ Frequency

□ Urgency

□ Burning or pain



□ Pain with sex

□ Hernia

□ Penile discharge

□ Sores


□ Pain with sex

□ Vaginal dryness

□ Hot flashes

□ Non-healing sores

□ Last dental exam

□ Pain

□ Stiffness

□ Self-exams

□ Breast-feeding

■ Shortness of breath (slight dyspnea)

□ Wheezing

■ Painful breathing

□ Shortness of breath with activity

(exertion dyspnea)

□ Difficulty

□ Rectal bleeding

□ Constipation

□ Diarrhea

□Yellow eyes or skin (jaundice)

□ Blood in urine (hematuria)

□ Incontinence

□ Change in urinary strength

□ Masses or pain

□ Erectile dysfunction

□ STD’s

□ Vaginal discharge

□ Itching or rash

□ STD’s


□ Calf pain with walking (Claudication) □ Leg cramping


□ Muscle or joint pain

□ Stiffness

□ Back pain

□ Redness of joints

□ Swelling of joints

□ Trauma


□ Dizziness

□ Fainting

□ Seizures

□ Weakness


□ Ease of bruising

■ Numbness (distal limbs)

□ Tingling

□ Tremor

□ Ease of bleeding


□ Head or cold intolerance

□ Sweating

□ Frequent urination (polyuria)


□ Nervousness

□ Depression

Physical Examination:

Consciousness: clear

Weight 70 kg; Height 168 cm

□ Thirst (polydypsia)

□ Change in appetite (polyphagia)

□ Memory loss

□ Stress

BP 130/70 (Right) 122/ 66 (left); PR: 90 RR: 21 BT 39

Conj: not pale

Sclera: not icteric

Neck: supple, LAP (-)

Chest:Insepection: reduced expansion over left side with a well functioning chest tube; spider angioma (-), gynecomastia (-)

Palpation: no crepitus

Percussion: resonance

Auscultation: BS: decreased over the left lower lung,

Heart: Inspection: PMI 5th intercostal space, 2 cm medial to the left mid-clavicular line Palpation: no heave, no thrill

Percussion: no increase of dullness

Ausculation: RHB, no murmur, normal splitting of S1 and S2, S3 (-), S4 (-)

Abdomen: Inspection: globular

Palpation: soft, no organomegaly, pain (-), tenderness (-), rebound (-)

Percussion: tympanic, No shifting dullness

Auscultation: BS: normoactive

Limbs: warm, no edema, cyanosis (-), lateral weakness (-), palmar erythema (-)

Peripheral pulse: symmetric and active

DRE: external hemorrhoids only

Laboratory data:

Biochemical test: sugar AC 140 mg/dL, AST 84, ALT 34, Total bilirubin 0.3, Cr 1.0,

LDH 132

CBC: WBC 12,000, Hb 12, Plt 240K,

Pleural effusion: pus like, LDH 1200, pH 7.1, WBC 1200 (70% of PMN)


CXR showed meniscus sign, indicates the presence of left pleural effusion.

Problem List:


Left pleural effusion, suspect Empyema


DM type II with neuropathy


Alcoholic liver disease

Assessment and Plan:

Problem 1: Left pleural effusion, suspect empyema


Infection should be first considered in diabetic patients (immunocompromised) with fever. The exudative character of left side pleural effusion plus leukocytosis indicates the infection foci of left pleural cavity. The pus nature, low pH and high LDH of pleural effusion diagnoses the presence of empyema. The usual cause of left side pleural effusion includes TB pleuritis and malignant pleural effusion and should be ruled out further.


Diagnostic: Record drainage amount, CBD D/C, CxR, Chest CT if necessary, pleural effusion cytology, AFS, TB PCR

Therapeutic: Cefoxitin 1gm iv Q6h, keep chest tube drainage, and consider to perform fibrinolytic therapy.

Education: care of chest tube and bottle

Problem 2: Diabestes Mellitus type II with neuropathy


Patient’s mother also has diabetes. Patient has had a history of diabetes mellitus for 15 years and is already using OHA to control the blood sugar. The numbness of distal limbs may indicate the diabetic neuropathy.


Diagnostic: 4 parts blood sugar by finger stick, HbA1c, U/A

Therapeutic: Glibenclamide 1# bid, Glucophage 1 tid, using RI scale if sugar higher than 250 mg/dL

Education: Current BMI 24.8 = overweight should better to reduce it to 23, HbA1c should be kept below 7.0

Problem 3: Alcoholic liver disease

Assessment: This patient has beer drinking for 20 years. There is no sign of cirrhosis on physical examination. The ratio of serum AST and ALT are more than

2. The serum bilirubin level is normal. Alcoholic liver disease is considered.


Diagnostic: GGT, Alk-p, abdominal sonography

Therapeutic: Thiamine 1 amp iv qd, Ativan (0.5) 1# hs

Education: Patient knows alcohol drinking is bad to health but he cannot sleep without alcohol. Besides, he feels his family relationship is not good that his wife and son do not care him much. He therefore, lacks of support and motivation to abstinent from alcohol. Further discussion with his family

and him is required and social worker will be consulted.


Question: Does fibrinolytic therapy for lobulated empyema add benefit to antimicromibial treatment?

Clinical bottom line:

Treatment with urokinase resulted in a significantly shorter hospital stay (7.4 v 9.5 days; ratio of geometric means 1.28, CI 1.16 to 1.41 p=0.027). A post hoc analysis showed that the use of small percutaneous drains was also associated with shorter hospital stay. Children treated with a combination of urokinase and a small drain had the shortest stay (6.0 days, CI 4.6 to 7.8).

Level of Evidence: Ia

Search terms :

P: Patients with empyema

I: Intrapleural urokinase

C: Anti-microbial alone

O: Hospital stay

References : Randomised trial of intrapleural urokinase in the treatment of childhood empyema Thorax 2002;57:343–347

Admission Order

Sep. 11, 2010

Admitted under the service of Dr. House

Diagnosis: Left pleural effusion, suspect empyema

Diabetes Mellitus type II with neuropathy

Alcoholic liver disease

Condition: Serious

Activity: Out of bed to chair

Vital sign: QID

Allergy: NKDA

Nursing: record chest drainage QD, CD chest tube wound QD, Finger stick for sugar

4 parts

Diet: DM diet 1800 cal

IV: N/S 500 ml + KCl 10 meq QD; D5W 500 ml + KCL 10 meq + RI 5U QD

Cefoxitin 1 gm IV Q6H

Thiamine(100mg) 1 amp IV QD

RI scale if sugar higher than 250 mg/dL

Medication: Glibenclamide(5mg) 1# bid,

Glucophage(500mg) 1 tid

Ativan (0.5mg) 1# hs

Laboratory: Check CBC, D/C, ALT, Cr, Na, K QW1, 4

CxR on next W1

Check GGT, Alk-p, HBsAg, HCV Ab, HbA1c st.

Arrange abdominal sonography


Progress Note

Sept. 12, 2010, 10:00 am

S: Pain on breath: better; pain of chest wound: still; less febrile

O: Consciousness: clear

BP 128/66; PR: 92; RR: 20; BT 38

Chest tube drainage 200 ml

Chest wound: slight erythema, no discharge

Sugar 224 in this morning

GGT 220; U/A: protein 60 g/L

Pleural effusion: GNB

Sonography: moderate fatty liver


Problem 1: left empyema

A: condition is improving, on cefoxitin 2 nd


P: Pursue the result of bacterial culture

Keep on antibiotic use and chest tube drainage

Problem 2: DM

A: Blood sugar slightly high, Proteinuria due to diabetes

P: check 24 hr protein loss, add insulin injection to OHA if sugar rises further

Problem 3: alcoholic liver disease

A: alcoholic fatty liver, stable

P: Keep Thiamine iv qd and ativan (0.5mg) 1 hs

Progress Note

Sept. 13, 2010, 10:30 am

S: No fever, insomnia, slightly tremor of hands, mild sweating

O: Consciousness: clear

BP 144/68; PR: 108; RR: 24; BT 36

Chest tube drainage 180 ml

Chest wound: slight erythema, no discharge

Fine tremor of hands

Skin: wet

Na 136, K 4.4, Sugar AC 180

Bacterial culture: Klebsiella pneumonia

Problem 1: left empyema

A: Kp empyema, improving, on cefoxitin 3rd day

P: Keep on antibiotic use and chest tube drainage; follow up CXR tomorrow

Problem 3: alcoholic liver disease

A: Mild alcoholic withdraw syndrome after no alcohol drinking for 2 days

P: (N/S + KCL 10 meq) x II QD; (D5W + KCL 10 meq) x II QD; Thiamine (100) 1 amp IV QD; Ativan (0.5) 2# tid and 4# hs; Inderal (10) 1# tid; Adalat (10) 1# prn if

SBP > 140; consult Psychiatrist